Provider Demographics
NPI:1750475562
Name:ROTH, KENNETH J (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:J
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:8695 SPECTRUM CENTER BLVD STE 130
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1489
Mailing Address - Country:US
Mailing Address - Phone:858-541-0181
Mailing Address - Fax:760-705-1533
Practice Address - Street 1:8765 AERO DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1767
Practice Address - Country:US
Practice Address - Phone:858-541-0181
Practice Address - Fax:858-430-0919
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-03-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG52650207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G526500Medicaid
CABJ295YOtherMEDICARE
CA00G526500Medicaid
CAA52313Medicare UPIN